Kuwait Pharmacy Bulletin DRUG INFORMATION FOR THE HEALTH PROFESSIONAL

Vol 19. No 3 Autumn 2015 ISSN 1028-0480

Background

Bisphenols are carbon-based synthetic phenolic

compounds containing two hydroxyphenyl groups.

The chemical structure of these compounds is

based on diphenylmethane, except for bisphenol S,

P and M. Phenolic compounds are generally weak

acids, however, they are considered relatively sta-

ble due to the existence of several mesomeric

structures.

The reactivity of phenolic compounds mainly

depends on the entire structure of the molecule and

the nature of the substitutes attached to the benzene

ring. The presence of hydrogen bonds affects their

solubility in water, the boiling and

melting point as well as the altera-

tion of its infra-red (IR) and ultra

violet (UV) spectra (Wilfred and

Ralph, 2006).

Bisphenol A (BP-A) is a monomeric compound

synthesized in the 1930s by Dodds and Lawson to

mimic the estrogenic effect in humans. In the

1950s, BP-A was employed in making epoxy res-

ins and polycarbonate plastics due to its desirable

chemical and physical characteristics (Joe and

Russ, 2011).

However, BP-A is a well-known endocrine dis-

rupter. It is the building block for polyvinyl chlo-

ride, polystyrene, phthalates and polycarbonate

plastics often used in various consumer products

including medical equipment, tableware, plastic

water bottles, toys, thermal receipts, pharmaceuti-

cal containers and food linings. Additional uses of

BP-A include common household and workplace

items such as the coating of CDs, DVDs, electrical

and electronic equipment, automobiles and sports

safety equipment (Beverly et al., 2011). Plastics

containing BP-A such as polycarbonate, polysul-

fone, polycrylates, polyetherimide and polyvinyl

chloride are used in manufacturing intravenous fluid

bags, respiratory masks, endotracheal tubes, umbili-

cal catheters, nasogastric and enteral feeding tubes.

Moreover, BP-A is involved in producing dental

composite resins, dental sealants and other dental

devices. Medical and dental materials have a direct

and long contact with patients with slow BP-A hy-

drolysis due to heat or a change in pH medium en-

countered in oral environment

(Hazardous Chemicals, 2015).

BP-A molecules are linked by

ester bonds which are suscepti-

ble to hydrolysis when exposed

to high temperatures or acidic and basic media lead-

ing to BP-A leakage from polyvinyl chloride, poly-

styrene, phthalates and polycarbonate plastics

(Welshons et al., 2006).

Recent studies cor-

relate serum and/or

urine BP-A levels

with various diseases,

health outcomes and

medical conditions

such as diabetes

(Shankar et al., 2011),

cardiovascular diseas-

es (Melzer et al.

Health risks of Bisphenol-A contamination

In this issue Health risks of BP-A 1 Test your knowledge 6 Topical issues 6 News from FDA 12 News from FoP KU 15 Drug bites 16

Although Bisphenol-A (BP-A) is an endocrine disrupter, it is used in a large variety of consumer products

including plastics, medical equipment, food linings and many other daily used items. BP-A leakage is en-

hanced by heat, acidic or basic pH as a result of ester bond breakage. Plastic toys are one of the main

sources of BP-A exposure during childhood. Since Kuwait is one of the hottest countries in the world, we

undertook a study to examine BP-A levels in four randomly chosen toys: plastic tiger, plastic Lego blocks,

plastic doll and other small dolls, and in two different brands of drinking bottled water. These items were

stored at 45⁰C for 4 days and then Bisphenol A was extracted with 1 L of water and samples were analyzed

by ultra-pressure liquid chromatography coupled with ultraviolet detector (UPLC-UV). This method has a

limit of detection (LOD) of 0.4 ppb and a limit of quantification (LOQ) of 1 ppb.

2 Kuwait Pharmacy Bulletin Autumn 2015

2010), carcinogenic risk (Vandenberg et al., 2009),

premature deliveries and breast cancer (Dodds et

al., 1936; Cantonwine et al., 2010), lowered semen

quality and sperm DNA damage in males (Meeker

et al., 2010; Li et al., 2011) as well as childhood

obesity and altered pubertal development

(Howdeshell et al., 1999) (Honma et al., 2002).

Although BP-A has a short (5-6h) biological half-

life, continuous exposure should be taken into con-

sideration since it is an endocrine disrupting agent

(Tinne et al., 2012).

Bisphenol A has been detected in varied types of

media including air, municipal water, soil, sedi-

ments and food items. Thus, people can be exposed

to BP-A through different sources. Although the

oral route is thought to be the main source of BP-A

exposure, inhalation and dermal routes are also

possible (Zalko et al., 2011) (Biedermann et al.,

2010). Orally, BP-A goes through first-pass metab-

olism in the liver, after absorption, by cytochromes

CYP450, mainly the CYP2C subfamily. Bisphenol

A-glucuronide is the major metabolite in human

hepatocytes because it is metabolised by glucuroni-

dation, phase II metabolism, and excreted in the

urine (Tinne et al., 2012).

Plastic toys are considered to be a major source

of BP-A during childhood as most such toys are

made of polyvinyl chloride and polystyrene plas-

tics; nevertheless toy manufacturers have never

precisely stated leakage risks or appropriate stor-

age conditions for their plastic products. In 2012

the FDA started to ban BP-A-containing resins in

babies’ feeding bottles and spill-proof cups due to

their potential harmful effects. Thus it became a

major concern for healthcare providers. According

to the European Food Safety Authority (EFSA),

the tolerable daily intake of BP-A should not ex-

ceed 50 µg/ Kg body weight/day (Beverly et al.,

2011). Different analytical methods have been es-

tablished for precise and accurate measurement of

BP-A levels.

Some studies have detected high levels of urinary

BP-A in school children, since they are always in

contact with plastic toys either by touching and /or

sucking. A study performed on 55 infants receiving

care in neonatal intensive care unit (NICU) showed

that infants who required 4 or more medical devic-

es had higher BP-A levels than those who required

3 or fewer devices (Susan et al., 2013).

It is known that gonadal hormones can be affect-

ed by exogenous endocrine disrupting chemicals

such as BP-A. Such disruption has a greater effect

in childhood due to the immaturity of the endocrine

system. Several studies have linked BP-A exposure

to chronic conditions such as diabetes, obesity, neu-

robehavioral deficits or diseases and male reproduc-

tive disorders, as well as the hormone dependent

cancers of the breast, prostate and ovary. BP-A was

shown to exhibit a weak estrogenic activity and

binds to androgen and thyroid hormone receptors

which can cause disrupting effects on thyroid hor-

mone production and signaling. John et al., (2011)

observed a significant decrease in T4 and TSH lev-

els associated with high urinary BP-A levels.

A cross-sectional study (Leonardo et al., 2012)

performed on 2838 randomly selected participants

aged from 6 -19y showed a direct relation between

BMI and BP-A urinary concentration. Thus, BP-A

has a potential role in increased body weight and

obesity. Moreover, BP-A was able to mimic the ef-

fect of 17β-estradiol (E2) on blood glucose homeo-

stasis in mice and therefore may be a contributing

factor in diabetes development (Alonso-Magdalena

et al., 2005). Although BP-A has a greater effect

during childhood, few studies have measured BP-A

levels in infants or children (Hui et al., 2015).

Experimental Methods A method was established at the laboratories of the

Pharmaceutical Chemistry Department, Faculty of

Pharmacy, Kuwait University to measure BP-A in

plastic toys (tiger toy, small doll, large doll, 4 Lego

blocks) and bottled drinking water using an ultra-

pressure liquid chromatography coupled with ultra-

violet detector (UPLC-UV).

Isocratic elution was carried out with a mobile

phase comprised of filtered and degassed 0.1% w/v

formic acid in water (pH 4) and acetonitrile in pro-

portion of 40:60 v/v and pumped at a flow rate of

0.1 ml/min. Column temperature was set at 45ºC

and samples were analyzed at a wavelength of 280

nm and were injected at 10 µl injection volume.

Waters® Acquity UPLC system with Binary Solvent

Manager, Sample Manager and UV detector, Wa-

ters® Acquity UPLC BEH C18, 1.7 um, 2.1 x 50

mm analytical column were used for analysis and

method validation. Empower® software was used

for data processing and reporting.

BP-A was simply extracted by dipping each plas-

tic toy and drinking bottled water in 1 L of HPLC

grade water and 1 ml was drawn using a Gilson pi-

pette and placed in 2 ml glass screw thread vials for

analysis. Analysis and extraction were done after

storing plastic toys and drinking bottled water at 45

Vol 19, No 3 Drug Information For The Health Professional 3

Samples were also analyzed in the mass spectrome-

ter to confirm that the peaks detected by UPLC-UV

were indeed BP-A (Fig 2).

Other peaks were eluted prior to the peak of inter-

est which are believed to be due to migration of dif-

ferent plasticizers from polycarbonate plastics,

which needs further study to be identified and quan-

tified. Blanks were analyzed between sample injec-

tions to ensure that the system was free from any BP

-A contamination. Linearity of detector response

was achieved with r2 value of 0.9999 by analyzing

five diluted concentrations (12, 240, 360, 480 and

600 ppb) of the stock solution.

The extracted BP-A levels were quantified using

the calibration curve generated during standard

analysis. In the current study, BP-A was found in all

randomly selected toys and one out of two randomly

selected bottled drinking water. The detected

amounts are below the daily tolerated dose stated by

the EFSA. However, the EFSA criteria have been

questioned as epidemiological and animal investiga-

°C for four days. A stock solution containing 1

ppm of BP-A dissolved in HPLC grade water was

used as a standard

RESULTS The linearity of the method was established with

five concentrations ranging from 12 ppb to 600

ppb. Plastic toys and drinking bottled water were

stored at 45 °C for four days and the amount of

leached BP-A analyzed (Table 1).

Fig 1 below shows, respectively, the chromato-

grams obtained for BP-A levels in the tiger toy and

the Lego blocks after storage at 45 °C for four

days.

Item BP-A levels after 12 h

exposure at 45 °C

BP-A levels after 4 days exposure at

45 °C Tiger toy 97.1 ppb 239 ppb

Small doll detection below LOQ 3 ppb

Big doll detection below LOQ 4 ppb

Lego blocks 1.3 ppb 30 ppb

bottled drinking water 1 50 ppb 59 ppb

bottled drinking water 2 ND ND

Abbreviations ND: Not detected, ppb: parts per billion, LOQ: Limit of quantification

Table 1. Analysis of BP-A levels in six randomly selected plastic products (four toys) and two brands

of bottled drinking water.

Fig 1. UPLC-UV analysis of BP-A levels in two

toys stored at 45°C for 4 days.

Fig 2. MS spectrum of BP- A

4 Kuwait Pharmacy Bulletin Autumn 2015

tions continue to demonstrate the harmful effects

of BP-A daily intake at doses below the current

reference daily tolerated dose (Richter et al., 2007;

Vandenberg et al., 2009). 1.3-1.8 ng/ml of urinary

BP-A concentration range was found to have ex-

ternalizing and internalizing behavioral effects in

2y-old children (Braun et al., 2009). Although the

highest estimated BP-A exposure in childhood is

believed to be due to polycarbonate plastic bottles,

canned foods with polycarbonate coating, con-

sumption of beverages lined with polycarbonate

bottles and microwaved foodstuff (WHO, 2010;

LaKind and Naiman,

2011), toys are persistent

and additive pathways of

BP-A exposure (Kim et

al., 2003).

The drinking water bot-

tles selected in the cur-

rent study were made

from polyethylene ter-

ephthalate (PET) resin of

the polyester family,

which is considered to be

safe and BP-A free (Shao

et al., 2005). However,

Tokunaga et al., (2008)

indicated an average con-

centration range of 3-10 ng/L of BP-A in drinking

water bottles made from PET. Therefore, the raw

material and the technology used in plastic bottle

production may contribute significantly to the BP-

A level present in drinking water (Amiridou et al.,

2011). Surprisingly, in the present study, 0.59 ppb

of BP-A was detected by the established method

in one of the randomly selected drinking water

bottles, which may be indicative of poor quality of

raw materials and/or poor production technology.

Thus, multiple sources of BP-A exposure can

increase levels of this potentially toxic compound

particularly in children, which may lead to serious

health complications. Our study agrees with other

results (Amiridou et al., 2011) indicating that BP-

A leakage increases with long storage time and

elevated temperature. Note that UPLC-MS-MS

technique remains the most efficient compared to

other techniques used in BP-A detection and quan-

titation.

HOW TO REDUCE BP-A EXPOSURE

BP-A is involved in every aspect of our daily life,

which makes it nearly impossible to avoid being

exposed to it. However, many health organisations

recommend ways of trying to reduce the exposure.

FDA recommendations are to breastfeed infants in-

stead of using infant milk formula because it will

contain less BP-A especially when the feeding moth-

er watches her diet and avoids canned food. In addi-

tion, discarding scratched plastic baby bottles, infant

feeding cups and other plastic food containers is

highly recommended because scratched plastic leaks

more BP-A than unscratched plastic.

FDA also recommends avoiding use of boiled or

very hot water in plastic bottles since heat enhances

BP-A leakage from plastic. They advise boiling water

in a BP-A free container

then mixing it with pow-

dered infant formula and al-

lowing it to cool to hand-hot

heat prior to putting it in a

plastic feeding bottle. FDA

also advises to only use

dishwasher safe and micro-

wave safe containers.

Generally, plastics with

recycle codes 1, 2, 4, 5, and

6 are unlikely to contain BP-

A, while plastics with recy-

cle codes 3 and 7 are more

likely to contain BP-A. FDA

urges manufacturers to de-

velop alternatives to BP-A and support any effort to

replace or minimize BP-A use in food cans linings

(FDA, 2015).

Moreover, the National Institute of Environmental

Health Sciences (NIH) has recommended to reduce

canned food consumption It encourages glass, porce-

lain, stainless steel containers and BP-A free baby

bottle usage. Yet, in Kuwait, many of these recom-

mendations are absent and there are no laws or regu-

lations regarding plastic usage and storing conditions

(NIH, 2015).

CONCLUSION BP-A is an endocrine disrupter whose exposure has

been linked to adverse health conditions as well as to

several diseases. The occurrence of BP-A in plastics

has raised many health concerns. Many research cen-

ters have developed extraction and analysis methods

for various types of samples that may contain and

leach out BP-A. The UPLC-MS-MS technique was

found to be superior in terms of sensitivity, selectivi-

ty and shortness of retention time when compared to

other techniques. Heat is a major factor for BP-A

leakage from plastics. In our study, BP-A was detect-

ed in all randomly selected plastic toys and one out of

Vol 19, No 3 Drug Information For The Health Professional 5

two randomly selected PET bottles of drinking

water. Therefore, imported mineral water should

be filled in a glass container rather than plastics

due to the high temperatures in Kuwait. Moreover,

toy manufacturers should use BP-A free plastics

or clearly specify storage

conditions of their plastic

products in order to prevent

potential health risks result-

ing from BP-A leaching.

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12. Joe M. B., and Russ H. Bisphenol A and children’s

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13. John D. M., and Kelly K. F. Relationship Between

Urinary Phthalate And Bisphenol A Concentrations

And Serum Thyroid Measures In U.S. Adults And Ad-

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14. Kim YH, Kim CS, Park S, Han SY, Pyo MY, and

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15. LaKind JS& Naiman DQ.

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Chemosphere 2011;82(3):424-30.

Ali B. Mohammad

Saleh

Final Year student

Faculty of Pharmacy,

Kuwait University

6 Kuwait Pharmacy Bulletin Autumn 2015

TEST YOUR KNOWLEDGETEST YOUR KNOWLEDGETEST YOUR KNOWLEDGE Is there a problem?

A child weighing 25 kg was given

the following prescription for a

fungal skin infection. Is there any

error with the prescription? major

Answer (Prescription Exercise)

The dose is incorrect. For a child

weighing less than 30 kg the dose

should be 100 mg once daily.

Source: British National Formulary

BMX HOSPITAL

Patient Name: Faisal Ali Age: 8 years

Address: Street No.28

Rx

Ketoconazole tablets

200 mg once daily

Send one pack

Dr. Roy

Signature Date: 5/09/15

1)Which of the following plastics-containing BP-A is used in manufacturing intravenous fluid bags, respira-tory masks and endotracheal tubes? a) Polycarbonate b) Polysulfone c) Polycrylates d) Polyetherimide e) All of the above 2) Which of the following medical conditions is not as-sociated with exposure to high levels of BP-A? a) Diabetes b) Cardiovascular disease c) Epilepsy d) Childhood obesity e) Cancer 3) Which of the following recycle codes indicate plastics that are more likely to contain BP-A? a) 1 b) 2 c) 3 d) 4 e) All of the above

TOPICAL ISSUES AND CONTROVERSIESTOPICAL ISSUES AND CONTROVERSIESTOPICAL ISSUES AND CONTROVERSIES

New medical ethics issues in cancer gene New medical ethics issues in cancer gene New medical ethics issues in cancer gene sequencingsequencingsequencing

Researchers are wrestling with what to look for in

genomic studies, how to handle the resulting infor-

mation and whether to contact patients for addi-

tional consent before genomic studies. Clinicians

want to know more about what constitutes a

"medically actionable" gene variant, how to re-

spect patient autonomy without shirking ethical

responsibility, and what to do about potential ge-

netic discrimination and the threats to privacy

posed by electronic medical records. Patients may

not be sure how much of this information they

want to know and may not have access to adequate

genetic counseling.

The rise of the incidentalome

Cancer genome studies are typically done by se-

quencing both a tumor cell and a normal cell from

the same patient. Subtracting the normal (germline)

sequence from the tumor cell sequence reveals the

tumor genome.

Once a genome is sequenced, the genomic infor-

mation immediately becomes electronic information

and there are problems of privacy protecting. A

viewpoint essay was published in the July 24/31 is-

sue of JAMA (2013;310:369-370) that addressed the

implications of balancing secondary genomic find-

ings with patient autonomy.

Researchers puzzle over what to look for

Genomics researchers are debating whether to set

limits on what they look for to avoid the ethical and

logistical complications associated with having "too

much information" about an individual patient. This

represents something of a pushback against the 2013

Answers on back page

Vol 19, No 3 Drug Information For The Health Professional 7

American College of

Medical Genetics and

Genomics (ACMG)

recommendation on

incidental findings,

which states that labor-

atories "seek and re-

port" 57 specific ge-

netic variants in all

clinical germline exo-

me and genome se-

quencing, "including

the 'normal' of tumor-

normal subtractive

analyses in all sub-

jects, irrespective of

age, but excluding fe-

tal samples." Twenty-

three of those muta-

tions pertain to cancer

risk.

It is recommended

that in retrospective

studies, germline vari-

ants should not be ex-

plicitly defined at the

time of tumor genetic analysis, as a way of striking

a balance between research goals and protecting

patient privacy.

According to experts, optimal interpretation of

the cancer genome requires a comparison with the

inherited genome, but it is possible to avoid explicit

listing of inherited variants. This strategy is justifia-

ble in retrospective genomic research, but is less

supportable in the prospective setting. For prospec-

tive studies, they recommend discussing disclosure

of incidental findings as part of the informed-

consent discussion.

Who knows? Who wants to know? And what

Is there to know?

Clinicians puzzle over what constitutes a

"medically actionable" genetic variant, what and

how to tell patients, and how to address genetic pri-

vacy issues such as the risk for genetic discrimina-

tion. Although the ACMG position is that infor-

mation about all "medically actionable variants"

should be given to the patient, there is no consensus

on what constitutes medically actionable. The 2

main types of medically actionable gene variations

are those associated with increased risk for cancer

or other diseases

and those with a

pharmacogenomic

impact that increas-

es or decreases

drug efficacy or

adverse effects.

There is certainly a

need for more em-

piric information

regarding what

kind of information

patients really want

to know and how

best to inform their

choices.

Steering through

a tsunami of

genetic

information

There will be a tsu-

nami of genetic in-

formation in the

next few years.

Doctors and patients don't understand it. There is a

huge need for education of everyone about it. There

is a huge shortage of genetic counselors. We are go-

ing to have all this information and not know how to

process it, how to interpret it, what to give to pa-

tients, or how to explain it to them.

This is a challenge for everyone involved in

medicine.

Developing personalized medicine depends on re-

searchers being able to access many people's ge-

nomes.

The Genetic Information Nondiscrimination Act

covers health insurance but does not cover life in-

surance, disability insurance, or long-term care in-

surance. If you apply for life insurance, the compa-

ny is within its right to ask, 'Have you ever under-

gone a genetic test? Has anyone in your family ever

undergone a genetic test? What was the result?' If it

included the BRCA1 breast cancer gene, the compa-

ny can refuse to insure you or can charge a much

higher rate. Genetic discrimination is very real and

is a problem.

For prospective research and clinical translation,

8 Kuwait Pharmacy Bulletin Autumn 2015

A recent paper showed that the high prices of can-

cer drugs are harming patients. The forum article

received a huge amount of publicity when it was

published online in

the journal Blood

and has spurred

American politicians

to action.

In the past 10

years, there has been

a dramatic increase

in the price of cancer

drugs. The average

price was about

$5000 before 2000

and by 2005, the av-

erage drug price

ranged from $30,000

to 50,000, and in 2012, nearly all of the new drugs

for cancer are priced over $100,000 in the US.

Some of the recent newcomers include 3 drugs for

chronic myeloid leukemia (CML) that were

launched in 2012: ponatinib (Iclusig, Ariad) which

costs $138,000 per year; omacetaxine (Synribo,

Teva), which costs $28,000 for induction and

$14,000 for a maintenance course; and bosutinib

(Bosulif, Pfizer), which costs around $118,000 per

year.

In addition, the new CML drugs were entering an

already crowded market. Hagop Kantarjian, from

the Department of Leukemia at the University of

Texas M.D. Anderson Cancer Center in Houston

and one of the authors of the paper, cited survival

data for CML patients as evidence of the harm that

drug prices can do.

In Sweden, where drug therapy is supplied to pa-

tients at no cost, the 10-year survival rates are 80%,

whereas, in the US, where CML patients have to

pay a proportion of the drug costs, leading some to

discontinue treatment, the 5-year survival rate is

only 60%.

The situation in other countries is even worse:

worldwide, only 20% to 30% of all CML patients

are taking these drugs; the rest cannot afford them.

In many emerging

countries, govern-

ments cannot afford

these drugs, and so

the front-line treat-

ment for CML is

stem cell transplan-

tation, which is not

suitable for all pa-

tients and which is

associated with early

mortality and long-

term morbidity.

In their paper, the

experts compare the

price of CML drugs in different countries around

the world- something that has not been done before.

There is so much variation in the price of the same

drug around the world.

It is clear from this comparison that the cost of

these CML drugs is 50% to 100% higher in the US

than anywhere else in the world. In the US, medical

costs have become a top cause of bankruptcy, and

Patients are harmed by high cancer drug costsPatients are harmed by high cancer drug costsPatients are harmed by high cancer drug costs

the path forward depends on approaches that better

define actionable variants and the development of

the evidence base and clinical infrastructure to sup-

port preference-based disclosure of incidental find-

ings, which will require the creation and evaluation

of decision tools and the clinical capacity to pro-

vide genomic counseling for which no standards of

care exist.

Source: Cancer Gene Sequencing Raises New Medi-

cal Ethics Issues. Medscape. Sep 06, 2013.

Country Imatinib Nilotinib Dasatinib Argentina 52,000 73,500 80,000

Australia 46,500 53,500 60,000

Canada 46,500 48,000 62,500

China 46,500 75,000 61,500

Germany 54,000 60,000 90,000

Japan 43,000 55,000 72,000

Mexico 29,000 39,000 49,500

Norway 50,500 61,000 82,500

Russia 24,000 48,500 56,500

S Korea 28,500 26,000 22,000

UK 33,500 33,500 48,500

USA 92,000 115,500 123,500

Estimated Annual Cost of CML Drugs by

Country (in US Dollars)

Vol 19, No 3 Drug Information For The Health Professional 9

Researchers are finding new drugs for chronic pain

and autoimmune diseases by modifying animal

venom-derived molecules that target the nervous

and immune systems. Animal venoms are a verita-

ble treasure of proteins and peptides fine-tuned by

millions of years of evolution to kill or incapacitate

both predator and prey. Their high molecular spec-

ificity and potency has long made them a promis-

ing source of drug candidates. More than 30 years

ago, the US FDA approved the first venom-derived

drug- a therapy for hypertension, called Capoten,

copied from a pit viper venom peptide.

Targeting autoimmunity The most compelling venom-derived drug current-

ly in development comes

from the sun anemone

(Stichodactyla helian-

thus), which lives on

reefs in the Caribbean. In

the 1990s, a group of physiologists at the University

of California, Irvine, showed that one of its toxins, a

peptide called ShK, is a potent inhibitor of a T lym-

phocyte potassium channel called Kv1.3, the up-

regulation of which is implicated in autoimmune

diseases.

To turn ShK into a useful therapeutic, however,

the researchers had to make one important change.

ShK is very potent on kv1.3 channels, but the big

problem is that it blocks another potassium channel

called kv1.1, found on neurons. After studying

From toxins to therapeutics From toxins to therapeutics From toxins to therapeutics

cancer is often the reason. A recent study found

that the rate of bankruptcy among those with a can-

cer diagnosis is double that of the rate in the gen-

eral population.

One of the solutions suggested is that the initial

price of a new cancer drug should be set according

to a value-based system, which would take into

account several parameters: the benefit in overall

or progression-free survival, improvement in quali-

ty of life, and the reduction of adverse effects and/

or cost when compared with existing therapies.

In their detailed review, the authors discuss the

many factors that contribute to the extremely high

prices of cancer drugs in the US, which can be 2 to

4 times the price charged for the same drugs in

other countries. They also make the point that even

within the US, cancer patients undergoing the

same treatment are charged differently according

to which medical insurance system they are in, and

some end up paying substantial amounts for cancer

drugs, especially the new oral agents, out of their

own pockets. Dr. Kantarjian and colleagues out-

lined a potential solution, which they believe

would result in a justum pretium, a "just price"

where the price reflects worth. By encouraging

prices based on real value, drugs should become

more affordable and their cost less burdensome to

patients and they also suggest that pharmaceutical

companies will be incentivized to "develop better

drugs that everyone can agree really are better."

Oncologists Can Change Prices That oncologists acting together can make an im-

pact on drug prices is illustrated by the recent case

of aflibercept (Zaltrap), for which the manufacturer,

Sanofi, cut the price drastically after protests. The

company was responding to a protest from oncolo-

gists at Memorial Sloan-Kettering who refused to

add the new drug to the hospital inventory because

it cost twice that of a similar agent, bevacizumab

(Avastin), used in the same setting. After the re-

searchers publicized their decision in an op-ed in the

New York Times, the company began offering dis-

counts that effectively halved the price of the new

drug. However, the discount by Sanofi doesn't really

address the problem, because Medicare reimburse-

ment and patient copayments are still based on the

higher list price. In other words, hospital and cancer

practices would pay less for the drug because of the

50% discount, but the reimbursement would stay the

same. This actually might give doctors and hospitals

a financial incentive to use aflibercept. Neverthe-

less, oncologists came together, took action, and had

an impact on drug pricing.

References:

1. http://www.medscape.com/viewarticle/810550

2. High Price of Cancer Drugs 'One of Biggest Is-

sues in Healthcare'. Medscape. May 23, 2013.

3. Cancer Drug Costs: Oncologists Must Be 'Part of

the Solution'. Medscape. Sep 06, 2013.

10 Kuwait Pharmacy Bulletin Autumn 2015

ShK’s structure and functional properties, they

tested almost 400 different synthetic derivatives of

the compound. They settled on a version featuring

an additional amino acid liked to the compound’s

N-terminus, which ensures it does not block ion

channels on cells other than T lymphocytes. The

resulting synthetic peptide- called ShK-186 binds

Kv1.3 channels with 100-fold greater potency than

Kv1.1 channels, all but eliminating the potential

for unforeseen side effects.

They later demonstrated in rodent models of

multiple sclerosis (MS) that ShK-186 dramatically

reverses paralysis. And importantly, the drug did

not broadly suppress the immune system, as treat-

ed animals were still able to fight off both chla-

mydia and influenza.

In December 2012, Seattle-based biotechnology

company Kineta completed Phase 1a human trials,

testing for the safety of ShK-186 in healthy volun-

teers. Although the results are yet to be published

and there is a long way to go before it hits the

clinic, ShK-186 currently holds great promise as a

treatment for a range of

autoimmune diseases,

from MS to lupus and

rheumatoid arthritis.

Fighting pain with

venom The first, and as yet, the

only approved venom-

derived drug that acts on

the nervous system is the

painkiller Prialt, a chemically identical version of

a peptide isolated from the cone snail (Conus ma-

gus). Approved in 2004, Prialt is injected into the

fluid around the spine, where it blocks a calcium

ion channel in neurons and inhibits the cells’ abil-

ity to transmit pain signals to the brain.

But there are several promising leads for new ven-

om-derived painkillers. Earlier this year, research-

ers at the National Center of Scientific Research

(CRNS) in Paris announced the discovery of two

peptides isolated from black mamba venom that can

block neuronal acid-sensing ion channels (ASICs),

which play a key role in the pain pathway. In mice,

these peptides, dubbed mambalgins, showed potent

analgesic effects, as powerful as morphine, with no

obvious toxicity and with less tolerance than mor-

phine. Researchers are now developing mambalgins

into a human pain therapeutic with the venom-

focused pharmaceutical company Theralpha.

Another painkilling peptide, also under develop-

ment by Theralpha, is derived from hannalgesin, a

neurotoxin isolated from King Cobra (Ophiophagus

Hannah) venom. Although the mechanism of action

for this peptide, known as THA903, is not yet clear,

pre-clinical studies have shown that it has a far

stronger analgesic effect than morphine and, crucial-

ly, can be taken orally.

Meanwhile, other researchers are continuing to

derive potential therapeutics from cone snails. Co-

nus catus, for example, a close

relative of Prialt’s source C.

magus, yields a toxin that the

Australia-based company Rel-

evare Pharmaceuticals has de-

veloped into an intravenous

treatment called Leconotide.

The drug blocks the same

channel as Prialt and is cur-

rently in Phase 1 trials.

These promising drug candi-

dates are likely just the tip of

the iceberg, researchers agree. It is estimated that

less than 0.1 % of the venom proteome of cone

snails- thought to harbour around 100,000 peptides.

In other words, we have millions of molecules that

are all potential drugs still to be explored.

Source: http://www.the-scientist.com/?articles.view/

articleNo/34745/title/From-Toxins-to-Therapeutics/

A Caribbean sun anemone (Stichodactyla helianthus)

Cone snail (Conus magus)

Black mamba (Dendroaspis polylepis)

Vol 19, No 3 Drug Information For The Health Professional 11

Seventeen years after Viagra, not a single medi-

cine has been formally approved for sexual prob-

lems in women. Now, the makers of a drug that

purports to boost a woman’s libido by targeting her

brain are launching their third attempt to

win American government approval, amid a debate

over whether there has been a gender bias in the

high-stakes field of sexual pharmacology- or a

manufactured cure for a medical disease that may

not exist.

The U.S. FDA is reviewing new safety data for

flibanserin, a once-a day Sprout Pharmaceuticals

drug that restores sexual desire in women by

“fixing” an imbalance of brain chemicals that drive

sexual excitement and inhibition. Unlike Viagra,

which is taken on an “as needed” basis before sex,

flibanserin must be taken daily.

Twice the FDA has rebuffed flibanserin, dubbed

“pink Viagra,” over safety and efficacy concerns,

leading to charges that the agency is sexist for ap-

proving sexual medicines for men, but not for

women. Other women’s groups are furious for

what they see as a hijacking of feminist rhetoric by

drug-company orchestrated campaigns designed to

put political pressure on regulators to approve a

pill for a “hypoactive” sex drive. Some believe that

low sexual drive is a significant problem for many

women and nothing is available to help women.

The executive director of Obstetricians in Canada

said that no one is asking to be turned into a teen-

ager again but young, vital active women want to

maintain a relationship with their partners and de-

serve such a solution.

More than 1,300 Canadian women have been

involved in tests of flibanserin. The drug was re-

jected by the FDA in 2010, and again in 2013, over

concerns the less-than-overwhelming benefit about

one extra “sexually satisfying event” per month,

compared to placebo, was outweighed by side ef-

fects such as dizziness, nausea, sleepiness hypoten-

sin, and fainting spells.

The FDA is granting Sprout a third hearing after

the North Carolina-based company submitted new

safety data, including a driving study conducted in

Montreal that found women who took flibanserin

at bedtime performed no worse the next morning

on simulated driving tests, compared with placebo.

Flibanserin was originally developed, but never

approved, as an antidepressant. Sprout says the

drug works on three neurotransmitters - dopamine,

norepinephrine and serotonin — that affect sexual

desire. It increases dopamine and suppresses seroto-

nin.

Feminists say there is no evidence that women

with low sexual desire have abnormal brain chemis-

try. But Sprout CEO Cindy Whitehead says brain

scans show there is something “biologically differ-

ent” occurring in women with low desire. Sprout

has come under fire from some women’s groups for

financially backing a campaign called “Even the

Score.” According to their website

(eventhescore.org), the count stands at “26-0″ for

the number of FDA approved drugs for sexual prob-

lems in men, versus those for women.

Opponents to this theory who work against the ap-

proval of flibanserin at the FDA, declare that for

many women - and men -having little spontaneous

sexual desire can be very normal.

On the other hand, Lori Brotto, an associate pro-

fessor in the department of obstetrics and gynecolo-

gy at the University of British Columbia who helped

develop psychiatry’s official criteria for the newly

named “female sexual interest/arousal disorder” said

no one single factor is behind loss of desire. She

said that neurobiology plays a role but sexual desire

isn’t rooted in an imbalance of neurotransmitters in

the brain. She suggested that part of helping women

is normalizing the changes that happen with age,

stress and mood, and encouraging women to engage

in activities that are actually arousing to them.

Source: news.nationalpost.com/.../drug-to-boost-womens

-sex-drive

Debate over “female Viagra”

12 Kuwait Pharmacy Bulletin Autumn 2015

Pertuzumab was set to be approved for the neoad-

juvant treatment of breast cancer in the preopera-

tive setting, based on the recommendation of a

FDA advisory panel.

At a meeting in Septem-

ber 2013, the FDA’s On-

cologic Drugs Advisory

Committee panel voted 13

-0, with 1 abstention, that

treatment with per-

tuzumab, a human epider-

mal growth factor receptor

2 (HER2)-targeted mono-

clonal antibody, had a fa-

vorable benefit-to-risk pro-

file as a neoadjuvant treat-

ment in combination with

trastuzumab and docetaxel

before surgery in patients

with locally-advanced, inflammatory, or early-

stage breast cancers greater than 2 cm in diameter.

The neoadjuvant approach would be part of a

complete early breast cancer treatment regimen

containing fluorouracil, epirubicin, and cyclophos-

phamide or carboplatin.

The drug is being reviewed under the accelerat-

ed approval process, a mechanism that makes

drugs available to fill an un-met medical need in

patients with serious diseases.

Historically, the usual sequence of the FDA ap-

provals for breast cancer agents starts with ap-

proval for metastatic disease, followed by approv-

al for early-stage disease years later after the re-

sults of large studies with long follow-up periods

are available.

Pertuzumab, marketed as Perjeta by Genentech,

was just approved in 2012 as a first-line treatment

for metastatic HER2-positive breast cancer in

women who have not received prior anti-HER2

therapy or chemotherapy for metastatic disease.

Accelerated approvals are based on a surrogate

endpoint that is considered “reasonably likely” to

predict clinical benefit. Pertuzumab was added to

trastuzumab (Herceptin) – another HER2 receptor

antagonist – and docetaxel, and was given before

surgery to women with HER-2-positive, locally ad-

vanced, inflammatory or early-stage breast cancer.

The comparator group was patients treated preopera-

tively with trastuzumab and

docetaxel.

The women who received the

three-drug neoadjuvant regi-

men had an 18% improvement

in pCR as compared to women

given trastuzumab and docet-

axel only.

The vote to support the first

approval of a drug for the neo-

adjuvant treatment of breast

cancer is a historic moment

with the hope that women with

earlier stages of breast cancer

will live longer and better.

NeoSphere, a randomized study conducted outside

of the United States, compared four treatment regi-

mens in 417 women newly diagnosed with locally

advanced, inflammatory or operable HER2-positive

early breast cancer, with tumors greater than 2 cm,

treated for four cycles before surgery. The median

tumor size was about 5 cm, and two-thirds were

node positive.

Based on the pCR definition used by Genentech

(the absence of invasive cancer in the breast), almost

46% of those on the combination of pertuzumab,

trastuzumab, and docetaxel reached the primary end-

point, compared with 29% of those on trastuzumab

and docetaxel – a statistically significant difference

of nearly 17%. Based on the FDA-preferred defini-

tion of pCR definition (the absence of invasive can-

cer in the breast and lymph nodes), the pCR rate was

almost 18% higher with the three-drug regimen

(39.3% vs. 21.5%).

The FDA considers pCR as “reasonably likely” to

predict outcomes in HER2-positive breast cancer.

Genentech also provided results from the TRY-

PHAENA phase II study that compared three neoad-

juvant treatment regimens before surgery; as well as

the CLEOPATRA phase III study, the basis of the

NEWS from the FDANEWS from the FDANEWS from the FDA

Panel backs approval of first neoadjuvant drug for breast cancer

Vol 19, No 3 Drug Information For The Health Professional 13

The US FDA revoked its approval of bevacizumab

(Avastin) for the treatment of metastatic breast

cancer. The drug costs about $90 000 (£58 000;

€68 000) a year and had created about $3.5bn in

sales annually for its manufac-

turer, Genentech.

FDA authorities state that the

drug had not been shown to be

safe and effective in metastatic

breast cancer. A review of stud-

ies did not show that the drug

extended the lives of women

with metastatic breast cancer and

women taking bevacizumab

risked life threatening side effects such as severe

hypertension, bleeding, heart attack, or heart fail-

ure, and perforations of the nose, stomach, and

intestine.

The European Medicines Agency (EMA) has

approved bevacizumab with paclitaxel for treating

metastatic breast cancer but the UK’s National

Institute for Health and Clinical Excellence

(NICE) has not recommended its use with taxane

drugs as first line treatment for the condition.

The FDA quickly approved bevacizumab for

breast cancer in 2008 under its accelerated approval

programme while studies were con-

tinuing. Those studies showed only a

small effect on tumour growth and

patients did not live longer or have a

better quality of life than those tak-

ing standard chemotherapy.

However, in June 2011 an FDA

advisory panel recommended the

drug be withdrawn but Genentech

objected and in public hearings pa-

tients pleaded for the drug that they said was keeping

them alive.

In 2013 the FDA finally revoked its approval for

bevacizumab in breast cancer. The drug, which

blocks blood vessel growth to tumours, is still ap-

proved for use in colorectal cancer, non-small cell

lung cancer, glioblastoma, and renal cancer.

The FDA’s decision has no direct effect on health

FDA cancels approval for bevacizumab in breast metastatic cancer

2012 approval of trastuzumab. In TRYPHAENA,

225 women with HER2-positive, locally ad-

vanced, operable or inflammatory breast cancer,

received one of three neoadjuvant treatment regi-

mens. The pCR rates, a secondary endpoint,

ranged from about 55% to 64% when pertuzumab

was added to trastuzumab and chemotherapy.

CLEOPATRA enrolled 808 women with HER2-

positive, locally recurrent, unresectable or meta-

static breast cancer previously untreated with a

biologic or chemotherapy for metastatic disease.

In that trial, pertuzumab in combination with

trastuzumab and docetaxel resulted in significant

improvements in progression-free survival and

overall survival.

The most common adverse events with the three

-drug regimen in the NeoSphere study were neu-

tropenia, diarrhea, nausea, fatigue, mucosal in-

flammation, and rash, according to the company.

No unexpected safety signals were observed with

the addition of pertuzumab. The addition of per-

tuzumab did not appear to increase symptomatic

cardiac toxicity when added to trastuzumab-based

neoadjuvant or metastatic treatment regimens.

The FDA reviewers noted, however, that the rate

of left ventricular dysfunction (mostly asymptomat-

ic) was higher with neoadjuvant pertuzumab treat-

ment. Cardiac toxicity appeared to be reversible,

however.

Panel member Deborah Armstrong of the Sidney

Kimmel Comprehensive Cancer Center at Johns

Hopkins, Baltimore, said that there were “some hints

of increased cardiac toxicity.” She encouraged the

company to closely evaluate patients on longer-term

pertuzumab in trials for cardiac toxicity.

Genentech has completed enrollment in the con-

firmatory, phase III APHINITY study, which will

compare chemotherapy plus trastuzumab with or

without pertuzumab before surgery in about 4,800

patients with HER-2 positive early breast cancer.

The patients will be followed for 10 years, and the

study will evaluate invasive disease-free survival.

Results are expected to be first available in 2016.

Source: http://www.practiceupdate.com/Explore/News/?

Id=3208&elsca1=emc_acq_splty-onc&elsca2=email

&elsca3=elsevier_oncologystat&elsca4=20130923_top-

articles&elsca5=acquisition

14 Kuwait Pharmacy Bulletin Autumn 2015

insurance or medical practice, neither of which it

regulates. However, health insurance companies

may decide not to reimburse patients for the drug,

although doctors may continue to prescribe it “off

label” for breast cancer patients. Medicare, the

health insurance programme for older people,

would continue to pay for the drug but would moni-

tor the situation. Genentech, the manufacturer, was

considering conducting a new phase III clinical trial

to see which patients might be helped by the drug.

Source: BMJ2011;343:d7684

FDA panel votes in favour of Olodaterol for COPD

The Pulmonary-Allergy Drugs Advisory Commit-

tee of the US FDA voted in favour of the data sup-

porting the efficacy, safety and approval of

Boehringer Ingelheim's olodaterol, a long-acting

beta-agonist, delivered via a metered dose inhaler

under the proposed trade name

Striverdi Respimat.

The proposed indication is

for long-term, once-daily

maintenance bronchodilator

treatment of airflow obstruc-

tion in patients with chronic obstructive pulmonary

disease (COPD), including chronic bronchitis and/

or emphysema. The proposed dose is two 2.5-μg

sprays once daily for a total dose of 5 μg olodat-

erol.

Exercise Tolerance Boehringer is also seeking FDA approval to make

claims in the product label about olodaterol's abil-

ity to increase exercise tolerance, increase inspira-

tory capacity at rest and during exercise, and re-

duce lung hyperinflation based on decreased func-

tional residual capacity. No COPD treatment cur-

rently on the US market makes such claims on

their product label.

No decision was reached on the labeling pro-

posal. Some panel members agreed with the FDA

analysis that despite a statistically significant 14%

improvement in exercise tolerance, as measured in

seconds, it was not clear to what degree that differ-

ence translated to clinically relevant improvement

for patients.

The manufacturer's data came from 7 dose rang-

ing/dose regimen trials (3 in COPD and 4 in asth-

ma), four 48-week trials, and six 6-week trials, 2 of

which were focused on exercise. The majority of

the trials permitted patients to continue taking usu-

al care background medications, including long-

acting anti-muscarinic agents (tiotropium), but not

other long-acting beta-agonists.

In contrast to data submitted to FDA for previous

bronchodilator treatments, the phase 3 studies for

olodaterol included patients with all levels of COPD

severity including approximately 10% with very

severe disease (Global Obstructive Lung Disease

stage IV). Also included were

patients with comorbidities, in-

cluding hypertension in about a

third of patients in the phase 3

studies.

The overall treatment effect at

12 weeks for the 5-μg dose was an average 65-mL

improvement in trough forced expiratory volume at

1 second and a mean 155-mL improvement in

forced expiratory volume at 1 second area under the

curve. No additional benefit was seen with the 10-

μg dose over the 5-μg dose.

There was a safety signal for neoplasms, with 3

patients (0.3%) in the 10-μg olodaterol group devel-

oping small cell lung cancers compared with no pa-

tients in the placebo group. Panel members agreed

with company officials that the difference may be a

result of chance and/or an imbalance in preexisting

neoplasms between the 2 groups but urged the FDA

to monitor for neoplasms specifically in pos-

tmarketing surveillance.

Source: http:www.medscape.comviewarticle/778459?

src=wnl_edit_medn_wir&spon=34Medscape Medical

News

Vol 19, No 3 Drug Information For The Health Professional 15

Changing the landscape of pharmacy education in Kuwait

Coherent with its newly defined vision, mission

and values, the Faculty of Pharmacy at Kuwait

University is embarking on an ambitious and need-

ed development program to strengthen the pharma-

ceutical sector in Kuwait. Our vision is to “Be rec-

ognized as an outstanding innovative leader in

pharmacy education and research, contributing re-

sponsibly to the continuous improvement of phar-

maceutical services and patient-centered care with-

in our community.”

One of the major

changes currently

under way at the

Faculty is the educa-

tional portfolio. In

addition to the cur-

rent B.Pharm (5

years) and the

M.Pharm (2+ years),

we are developing a

2-year add-on

PharmD, scheduled

to start in September

2016, to improve

clinical pharmacy education. The BPharm and the

PharmD are then expected to be later merged into a

single entry-to practice PharmD. The Faculty is

also planning a PhD in pharmaceutical sciences to

increase the number of highly qualified personnel

in the pharmaceutical sector. The development of

new academic programs will incorporate several

active-learning approaches as well as an important

proportion of experiential learning activities to help

students integrate faster within their future work

environment.

To support the current workforce, the Faculty

will continue to offer a range of continuing profes-

sional development (CPD) activities, targeting

pharmacists and employees working for the Minis-

try of Health, community pharmacists, industrial

pharmacists and other employees of the pharma-

ceutical industry that have CPD needs. In partner-

ship with the major stakeholders and current con-

tent providers, the new Offices of Consultation,

Studies and Training and of Strategic Alliances will

be instrumental in expanding the scope of our cur-

rent lectures and courses.

The scientific research conducted at the Faculty

is currently amongst the best at Kuwait University.

In recognition of the need for a multidisciplinary

approach to modern research, the Faculty intends

to consolidate its research activities by establishing

specialised Units that will have a “bench to bed-

side” philosophy in order to bring fundamental ide-

as closer to therapeutic applications.

Fresh from its recent “Let’s practice green” an-

nual campaign and a first experience of a public

awareness open day on cancer in February 2015,

the Faculty will initiate

activities designed to

increase its patient out-

reach and visibility.

An example is the re-

cent development of a

Medicines Information

Center (MIC) to pro-

vide a precise, updated

service to physicians,

pharmacists and other

healthcare personnel.

In the future, the Fac-

ulty plans to have a

clinic, to become a na-

tional training center for pharmacists to develop

pharmaceutical care services, where cognitive ser-

vices will be offered to health care professionals

and patients alike. Its aim will be to optimise the

use of medicines for patients having complex med-

ication therapy issues.

Finally, there is a need to expand the scope of

practice for pharmacists, to enable future graduates

to utilise the full extent of their training for the

health and well being of the Kuwaiti population.

This has to be done in conjunction with the devel-

opment of standards of practice that are based on

credentials obtained by formal education. The Fac-

ulty is participating in this effort in close collabora-

tion with the Ministry of Health and the Kuwait

Pharmaceutical Association.

You may be asked to participate in any of those

initiatives in the future and we welcome any feed-

back and suggestions (pmoreau@hsc.edu.kw).

P Moreau,

Dean, Faculty of Pharmacy, Kuwait University

NEWS from the Faculty of Pharmacy Kuwait UniversityNEWS from the Faculty of Pharmacy Kuwait UniversityNEWS from the Faculty of Pharmacy Kuwait University

16 Kuwait Pharmacy Bulletin Autumn 2015

Answers to: Test your knowledgeAnswers to: Test your knowledgeAnswers to: Test your knowledge Correct answers:

1-e; 2-c; 3-c

The Kuwait Pharmacy Bulletin (ISSN 1028-0480) is published quarterly by the Faculty of Pharmacy, Kuwait University, and includes a list of recently approved drugs from the MOH. It aims to provide instructive reviews and topical news items on a range of drug related issues. It is widely distributed free within the university, to hospitals, polyclinics & private pharmacies as well as to other universities within the Gulf & Middle East region.

The information in this bulletin does not necessarily reflect the views of the editorship, nor should it be taken as an endorsement of any product that is mentioned herein. Articles are generally adapted from literature sources and rewritten or occasionally reproduced with permission from the appropriate sources. Readers wishing their own copy may ask to be added to the mailing list by contacting the Executive Editor. Executive Editor: Yunus Luqmani. Assistant Editors: Leyla Hasan Sharaf, Samuel Koshy

Editorial Office: Faculty of Pharmacy, Health Sciences Centre, Kuwait University, PO Box 24923 Safat, 13110 Kuwait, Fax:25342087; email: yunus@hsc.edu.kw

According to the IMS Institute for

Healthcare Informatics, a US company that

tracks sales at the pharmacy level for drug

companies, total drug spending in the US in

2014 was $374 billion, 13% higher than in

the previous year.

The most commonly prescribed drugs are

used to treat a variety of ailments - from pain relief to high blood pressure and high cholesterol. Prescrip-

tions for the following were close to or exceeded 100 million.

Levothyroxine for treatment of hypothyroidism, a condition in which the thyroid gland doesn’t pro-

duce enough thyroid hormone. This drug is also used to treat thyroid cancer and to help shrink an en-

larged thyroid gland.

Hydrocodone/acetaminophen is America’s most popular painkiller used to treat moderate to severe

pain. Hydrocodone, a narcotic analgesic, relieves pain through the central nervous system, and is used to

stop or prevent coughing. This drug can become habit-forming when used over an extended period of

time.

Lisinopril (which used to be sold under the brand names Zestril and Prinivil) is a high blood pressure

medication. Its main function is to block chemicals in the body that trigger the tightening of blood vessels.

Lisinopril is also used to treat heart failure.

Metoprolol, the generic version of Lopressor, is used to treat high blood pressure and also helps re-

duce the risk of repeated heart attack. Metoprolol also treats heart failure and heart pain, or angina.

Atorvastatin, the generic of Lipitor, is prescribed to treat high cholesterol and is typically recom-

mended in conjunction with diet changes. This drug is believed to have a variety of benefits, including

helping prevent heart attacks and strokes.

Adapted from https://www.nerdwallet.com/blog/health/2015/06/01/commonly-prescribed-drugs-america/

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